Waldron, William tt ZZ
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last ( Sex
William J. Waldron ( Male
Date of Death Age If Veteran of U.S. Armed Forces,
January 4,2012 60 War or Dates
Place of Death Hospital, Institution or
Z City, Town or Village Glens Falls I Street Address Glens Falls Hospital
p Manner of Death X Natural Cause Accident Homicide I I Suicide Undetermined Pending
to Circumstances Investigation
0
W Medical Certifier Name Title
0 _ Frances C.Bollinger
Address
100 Broad Street,Glens Falls,NY 12801
Death Certificate Filed District Number I Regi iip, umber
City, Town or Village Glens Falls 5601
❑Burial Date Cemetery or Crematory
January 9,2012 Pine View Crematory
Entombment
Address
Li Cremation Quaker Rd.,Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
O and/or Address
H Hold
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O Date I Point of
1(35 I I Transportation 1 Shipment
p by Common Destination
Carrier
Disinterment Date ' Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Alexander-Baker Funeral Home 00035
Address
3809 Main Street,Warrensburg,NY 12885
Name of Funeral Firm Making Disposition or to Whom
I— Remains are Shipped, If Other than Above
2 Address
CL
ul
0-
Permission is hereby ranted to dispose of the human remains descri e a ovv i c ted.
Date Issued 0/ S.20/Z Registrar of Vital Statistics
(signature)
District Number 5601 Place Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
H �
W Date of Disposition i- It-(2 Place of Disposition !14 t{u,✓ ( Tariv ..
2 (address)
W
W (section) (lot num (grave number)
or '
p Name of Sexton or Person in Char e of Premises 1i
Z (please print)
W Signature Title a eMq-14.
(over)
DOH-1555 (02/2004)